A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess for neck vein distention
Monitor for postural hypotension
Assess blood glucose level
Monitor for an irregular heart rate
Weigh the client daily
Correct Answer : A,C,D,E
A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.
B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.
C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.
D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.
E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.
B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.
C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.
D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.
E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.
Correct Answer is D
Explanation
A. 4 oz diet soda: Diet soda contains artificial sweeteners, not real sugar, and therefore will not effectively raise blood glucose levels. It's not suitable for treating hypoglycemia.
B. 1 tsp sugar: While 1 tsp of sugar can provide some glucose, the amount is insufficient to treat hypoglycemia effectively. The American Diabetes Association recommends 15 grams of fast-acting carbohydrates, which is equivalent to about 4 teaspoons of sugar, not 1.
C. 4 oz skim milk: Skim milk contains both carbohydrates (approximately 12 grams of carbohydrates per 8 oz, so 4 oz would provide around 6 grams) and protein. While it can help raise blood glucose, it may not provide the recommended 15 grams of fast-acting carbohydrates to treat hypoglycemia quickly enough.
D. Graham crackers: Foods with a high glycemic index (GI), such as graham crackers, can cause blood sugar levels to rise relatively quickly. Graham crackers, being high in refined carbohydrates, can indeed result in a rapid increase in blood glucose levels compared to low-GI foods.
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